Your disability hearing will be held soon. Please complete this Activities Questionnaire and bring it to the meeting we have scheduled to prepare you to testify.

Read through this form before you fill it out. Spend a few days thinking about the activities listed on the form and the many ways your life has changed because of your health problems. Talk with family members and friends about their observations. Then, in the days before you meet with us, complete the form in as much detail as possible.

For each of the activities listed, describe the way these things are done differently now (or not performed at all) compared to the way they were performed before you became disabled. For each activity, some possibilities are suggested in parentheses; but these are only suggestions to start you thinking. List changes in the way the activities are performed, however small the difference may seem. If you now perform these activities only on “good days,” be sure to say so. State the reasons the activities are now performed differently. Explain. The details help.

Thank you.

1. Driving (no longer drive, drive less often, drive only short distances, difficulty getting into or out of the car, got handicapped parking permit, get lost while driving, use bigger car, accidents, make frequent stops):

8. Laundry including washing, drying, ironing, folding (wash clothes less often, get assistance doing or carrying laundry, throw rather than carry laundry down the steps, stay in basement while doing laundry, carry only a few items at a time, take more clothes to cleaner, buy more permanent press clothes):

14. Grocery shop (do not shop alone, shop when crowds are smaller and lines shorter, rest while shopping, lean on car, smaller bags, use express checkout, delivery by store, buy smaller containers, get dropped off and picked up at store entrance, buy more convenience foods such as TV dinners, sandwiches, microwave foods):

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15. Pay bills / handle finances:

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16. Watch / play with children:

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17. Watch TV / listen to radio (watch more, TV no longer keeps my interest, trouble concentrating on what is going on, shorter attention span, watch more while in bed or on recliner, more frequent breaks, nose makes me nervous):

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18. Read (need to reread sections to understand, do not remember what was read, read for shorter periods of time, read shorter pieces such as magazines instead of novels, stopped reading the newspaper):

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19. Talk with others, including telephone (want to be left alone, initiate conversations less often, talk for shorter periods of time):

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20. Sleep at night (different times to go to bed and get up, trouble falling asleep, restlessness, get out of bed during night, inability to sustain sleep, feel tired when getting up, use sleeping pills, extra pillows under head or legs):

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21. Sleep/rest during day (naps, rest periods, time spent in bed, couch or recliner):

30. Identify all interests and hobbies you used to enjoy. Why and how you do them differently now or not at all? (For example, fishing, crossword puzzles, hunting, sports, knitting, collecting, rummage sales, musical instruments, woodworking, golfing):

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